Mulberry House

People, relatives and staff said staffing levels were safe. Recruitment checks had improved and the provider was no longer in breach of the staffing recruitment regulation.

“People, staff and relatives all told us they felt that staffing levels were safe within the service.” from the report

Inspectors found that medicines were given as prescribed, stored securely and recorded accurately.

“People received their medicines as prescribed, on time and in the way they preferred them by competent staff.” from the report

Staff had safeguarding training and understood how to recognise and report abuse. People and relatives told inspectors they felt safe.

“Staff understood the signs of abuse and how to report it. They were trained in safeguarding and felt confident in reporting any concerns.” from the report

People received healthcare support when needed. Staff noticed changes in health and arranged timely help from health professionals.

“Staff were vigilant about any changes to people's health and wellbeing and ensured people received timely support from health professionals.” from the report

People and relatives were involved in care planning where possible. Inspectors saw respectful support for privacy, dignity and independence.

“People's views regarding their care were sought and they were empowered by staff to make decisions about their care.” from the report

Known risks were not always assessed or recorded. This included risks linked to distressed behaviour and a damaged bathroom, increasing the risk of harm.

“These failures to effectively assess risk, and to maintain a safe and clean environment, was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

Inspectors found stained and odorous bedding, mould and damaged walls, a soiled bin, marked surfaces and sticky floors. Action to replace faulty equipment had not been taken promptly.

“Several areas within the home were not clean. A bin outside the kitchen area was heavily soiled and the lid was open.” from the report

People's interests, goals and aspirations were not consistently recorded or supported. Some people were observed sitting without engagement.

“These failures to promote and document activity, aspiration, and goals with people, were a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

Management checks did not identify or resolve repeated problems. Staff described poor communication and low morale, and the provider remained in breach of good governance requirements.

“These failures to assess, monitor and mitigate risks within the service, and failure to maintain a positive culture and ensure appropriate standards were met, was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

Targets for one-to-one supervision were not met. Staff said formal support from management was infrequent, limiting the home's ability to identify and deal with concerns promptly.

“This meant that management were not fully identifying any concerns within the staff team and dealing with them in a timely manner.” from the report

Food stocks were minimal and largely consisted of cheaper value brands. Managers agreed to review the food bought after inspectors raised concerns about its quality.

“We pointed out that the impact of these actions was lower quality food for people, which was not a fair outcome for the people using the service.” from the report